An Epidemic of Scurvy in Afghanistan: Assessment and Response

High prevalence of adult and nonadult scurvy in an early agricultural transition site from Mainland Southeast Asia was associated with decreased survivorship

OBJECTIVES

The osteological paradox recognizes that the presence of lesions is not always directly related with increased mortality. When combined with the clinical, historical, and epidemiological literature on scurvy, survivorship analysis, a form of statistical analysis to assess the relationship between the presence of diseases in the archeological record and survival, helps determine the overall burden of the disease both in terms of morbidity and mortality. This article explores the relationship between scurvy and survivorship in 26 adults from Man Bac, a Neolithic site from northern Vietnam together with prepublished evidence of scurvy in the nonadult population (n = 44).

METHODS

Diagnosis of scurvy included differential diagnosis combined with the Snoddy, A. M. E., Buckley, H. R., Elliott, G. E., Standen, V. G., Arriaza, B. T., & Halcrow, S. E. (2018). Macroscopic features of scurvy in human skeletal remains: A literature synthesis and diagnostic guide. American Journal of Physical Anthropology, 167(4), 876-895. https://doi.org/10.1002/ajpa.23699 threshold criteria and the Brickley, M. B., & Morgan, B. (2023). Assessing diagnostic certainty for scurvy and rickets in human skeletal remains. American Journal of Biological Anthropology, 181, 637-645 diagnostic certainty approaches. Kaplan-Meier survival curves were produced to assess the relationship between the presence of probable scurvy and age-at-death.

RESULTS

The prevalence of probable scurvy in adults (35%) was considerably lower than reported for the nonadults (80%). Almost all lesions observed in the adults were in a mixed stage of healing. Kaplan-Meier analysis demonstrated no difference in survivorship between infants and children (<15 years) with or without probable scurvy, whereas a meaningful difference was observed for the adults and adolescents (15+ years).

CONCLUSIONS

The findings demonstrate that scurvy considerably decreased survivorship to older age categories. The degree of lesion remodeling, however, indicates that scurvy was not necessarily the direct cause of death but contributed to an overall disease burden that was ultimately fatal.

Prioritizing strategies for wheat biofortification: Inspiration from underutilized species

The relationship between malnutrition and climate change is still poorly understood but a comprehensive knowledge of their interactions is needed to address the global public health agenda. Limited studies have been conducted to propose robust and economic-friendly strategies to augment the food basket with underutilized species and biofortify the staples for nutritional security. Sea-buckthorn is a known "superfood" rich in vitamin C and iron content. It is found naturally in northern hemispherical temperate Eurasia and can be utilized as a model species for genetic biofortification in cash crops like wheat. This review focuses on the impacts of climate change on inorganic (iron, zinc) and organic (vitamin C) micronutrient malnutrition employing wheat as highly domesticated crop and processed food commodity. As iron and zinc are particularly stored in the outer aleurone and endosperm layers, they are prone to processing losses. Moreover, only 5% Fe and 25% Zn are bioavailable once consumed calling to enhance the bioavailability of these micronutrients. Vitamin C converts non-available iron (Fe3+) to available form (Fe2+) and helps in the synthesis of ferritin while protecting it from degradation at the same time. Similarly, reduced phytic acid content also enhances its bioavailability. This relation urges scientists to look for a common mechanism and genes underlying biosynthesis of vitamin C and uptake of Fe/Zn to biofortify these micronutrients concurrently. The study proposes to scale up the biofortification breeding strategies by focusing on all dimensions i.e., increasing micronutrient content and boosters (vitamin C) and simultaneously reducing anti-nutritional compounds (phytic acid). Mutually, this review identified that genes from the Aldo-keto reductase family are involved both in Fe/Zn uptake and vitamin C biosynthesis and can potentially be targeted for genetic biofortification in crop plants.

Investigation of an outbreak of disease compatible with scurvy in a male penitentiary in the state of Ceará, Brazil, 2019-2020: a case-control study

MAIN RESULTS

An outbreak of illness compatible with scurvy occurred among male prison inmates; most frequent signs/symptoms were edema and pain in lower limbs, difficulty in walking and hematoma/ecchymosis; the associated factor was age > 40 years.

IMPLICATIONS FOR SERVICES

The results can contribute to the identification and description of scurvy outbreaks in other contexts and territories. Epidemiological studies of events like this enhance the practice of field epidemiology in health services.

PERSPECTIVES

It is expected that the prevention of hypovitaminosis, such as scurvy, will be based on public policies aimed at the population deprived of liberty; and that the capabilities of health services to detect and respond to cases of the disease will be improved.

OBJECTIVE

to identify the occurrence of an outbreak compatible with scurvy and exposure factors associated with typical signs/symptoms of hypovitaminosis that occurred in a male penitentiary in Ceará, Brazil between 2019-2020.

METHODS

this was a population-based case-control study; we used clinical records and interviews with compatible cases - based on sign/symptom onset during the study period - and with controls; we carried out multivariate analysis.

RESULTS

out of 62 cases, mean age was 40.6 years (SD = 10.8); main signs/symptoms were edema and pain in the lower limbs (100.0%), difficulty in walking (91.9%), hematoma/ecchymosis in the lower limbs (90.3%) and fever (88.7%); we identified being over 40 years old as an associated factor (aOR = 1.10; 95%CI 1.05;1.17; p-value = 0.001); and as protective factors: working (aOR = 0.11; 95%CI 0.03;0.36; p-value < 0.001) and taking part in classes (aOR = 0.21; 95%CI 0.08;0.59; p-value = 0.003) in the prison.

CONCLUSION

we considered the penitentiary outbreak to be compatible with scurvy due to characteristic signs/symptoms, associated with the identified factors; we recommended regular provision of a diet rich in vitamin C to all male inmates and clinical follow-up of cases.

Vitamin C fortification: need and recent trends in encapsulation technologies

The multifaceted role of vitamin C in human health intrudes several biochemical functions that are but not limited to antioxidant activity, homoeostasis, amino acid synthesis, collagen synthesis, osteogenesis, neurotransmitter production and several yet to be explored functions. In absence of an innate biosynthetic pathway, humans are obligated to attain vitamin C from dietary sources to maintain its optimal serum level (28 μmol/L). However, a significant amount of naturally occurring vitamin C may deteriorate due to food processing, storage and distribution before reaching to the human gastrointestinal tract, thus limiting or mitigating its disease combating activity. Literature acknowledges the growing prevalence of vitamin C deficiency across the globe irrespective of geographic, economic and population variations. Several tools have been tested to address vitamin C deficiency, which are primarily diet diversification, biofortification, supplementation and food fortification. These strategies inherit their own advantages and limitations. Opportunely, nanotechnology promises an array of delivery systems providing encapsulation, protection and delivery of susceptible compounds against environmental factors. Lack of clear understanding of the suitability of the delivery system for vitamin C encapsulation and fortification; growing prevalence of its deficiency, it is a need of the hour to develop and design vitamin C fortified food ensuring homogeneous distribution, improved stability and enhanced bioavailability. This article is intended to review the importance of vitamin C in human health, its recommended daily allowance, its dietary sources, factors donating to its stability and degradation. The emphasis also given to review the strategies adopted to address vitamin c deficiency, delivery systems adopted for vitamin C encapsulation and fortification.

When the limp has a dietary cause: A retrospective study on scurvy in a tertiary Italian pediatric hospital

The limping child frequently represents a diagnostic challenge. The differential diagnosis is broad and should include vitamin C deficiency. Scurvy, resulting from vitamin C deficiency, is the oldest-known nutritional disorder. Despite its rarity in developed countries, scurvy has been increasingly reported in recent years in pediatric patients, particularly those with autism or neurological disabilities. In the present retrospective study, we describe the clinical, laboratory, and radiological features of 8 patients diagnosed with scurvy in the Pediatrics Unit of Meyer Children's University Hospital, between January 2016 and December 2021. The majority (87%) were males, and the median age was 3.7 years. Half of the patients had comorbidities known to be risk factors for scurvy, while the remaining patients were previously healthy. All the children were admitted for musculoskeletal symptoms, ranging from lower limb pain (87%) to overt limping (87%). Mucocutaneous involvement was observed in 75% cases. Microcytic anemia and elevated inflammatory markers were common laboratory findings. Bone radiographs, performed on all patients, were often interpreted as normal at first, with osteopenia (62%) as the most frequent finding; notably, after re-examination, they were reported as consistent with scurvy in four patients. The most common magnetic resonance imaging findings were multifocal symmetrical increased signal on STIR sequence within metaphysis, with varying degrees of bone marrow enhancement, adjacent periosteal elevation and soft tissue swelling. Differential diagnosis was challenging and frequently required invasive diagnostic procedures like bone marrow biopsy, performed in the first three patients of our series. The median time frame between clinical onset and the final diagnosis was 35 days. Notably, the interval times between admission and diagnosis become progressively shorter during the study period, ranging from 44 to 2 days. Treatment with oral vitamin C led to improvement/resolution of symptoms in all cases. In conclusion, scurvy should be considered in the differential diagnosis in a limping child, performing a detailed dietary history and careful physical examination, looking for mucocutaneous lesions. A quick and correct diagnostic path avoids invasive diagnostic procedures and reduces the risk of long-term complications.

Food insecurity and mental health of women during COVID-19: Evidence from a developing country

BACKGROUND

This study examines the association between food insecurity and mental health of women during the COVID-19 pandemic in a resource poor setting.

MATERIALS AND METHODS

Data were collected at two time-points (wave 1 and 2) from 2402 women, one per household, participating in a larger study during extended COVID-19 lockdown in the rural areas of the southwest region of Bangladesh. The primary outcome of the analyses is the association between food insecurity, measured using the Food Insecurity Experience Scale (FIES), and stress level, measured using the Perceived Stress Scale (PSS), for women during the lockdown. General awareness about COVID-19 and attitude towards prescribed preventive measures were also measured since COVID-19 health concerns could exacerbate food insecurity.

RESULTS

An individual-level evaluation of the effect of wave 2 FIES score on PSS score showed that worsening of the food security status increasing the stress level of the participants (95% CI: 1.61; 2.13; p-value: <0.001). Additionally, a significant negative association was observed between the PSS score and change in food security status between the two waves (Coefficient: -1.15, 95% CI: -1.30; -0.99, p-value: <0.001), indicating that deterioration in food security status over the pandemic period increasing the stress level. At the village level, the results showed a similar pattern. General awareness around ways coronavirus spreads was high, yet there were misperceptions at a higher level. Maintaining hand hygiene, wearing face masks outside the home, and going outside only when necessary were widely practised. Fewer respondents could maintain a 1.5-metre distance from others in the outside and maintained cough and sneeze etiquette.

CONCLUSION

The results indicate a higher stress level, a potential contributor to poor mental health, as food insecurity deteriorated. Policy initiatives in ameliorating immediate food insecurity during crises, improving long-term wellbeing, and expanding the reach of mental health support are warranted.

Paediatric scurvy: frequently misdiagnosed

Paediatric scurvy is uncommon in the modern age but cases have been reported in children with neurodevelopmental issues and restricted dietary habits. The broad clinical picture is frequently overlooked as primarily other systemic diseases are considered first leading to extensive investigations and delay in diagnosis. A 4-year-old boy with autism and bilateral lower limb pain and refusal to walk is reported. His restricted diet and radiographic findings were highly suggestive of scurvy which was confirmed by the extremely low levels of ascorbic acid. Treatment with ascorbic acid replenishment and maintenance resulted in remarkable improvement. This case highlights the importance of a high index of suspicion in at-risk children so as to avoid unnecessary invasive investigations and procedures.

Global Vitamin C Status and Prevalence of Deficiency: A Cause for Concern?

Vitamin C is an essential nutrient that must be obtained through the diet in adequate amounts to prevent hypovitaminosis C, deficiency and its consequences-including the potentially fatal deficiency disease scurvy. Global vitamin C status and prevalence of deficiency has not previously been reported, despite vitamin C's pleiotropic roles in both non-communicable and communicable disease. This review highlights the global literature on vitamin C status and the prevalence of hypovitaminosis C and deficiency. Related dietary intake is reported if assessed in the studies. Overall, the review illustrates the shortage of high quality epidemiological studies of vitamin C status in many countries, particularly low- and middle-income countries. The available evidence indicates that vitamin C hypovitaminosis and deficiency is common in low- and middle-income countries and not uncommon in high income settings. Further epidemiological studies are required to confirm these findings, to fully assess the extent of global vitamin C insufficiency, and to understand associations with a range of disease processes. Our findings suggest a need for interventions to prevent deficiency in a range of at risk groups and regions of the world.

Factors Affecting Vitamin C Status and Prevalence of Deficiency: A Global Health Perspective

A recent review of global vitamin C status has indicated a high prevalence of deficiency, particularly in low- and middle-income countries, as well as in specific subgroups within high-income countries. Here, we provide a narrative review of potential factors influencing vitamin C status globally. The in vivo status of vitamin C is primarily affected by dietary intake and supplement use, with those who supplement having a higher mean status and a lower prevalence of deficiency. Dietary intake can be influenced by cultural aspects such as traditional cooking practices and staple foods, with many staple foods, such as grains, contributing negligible vitamin C to the diet. Environmental factors can also affect vitamin C intake and status; these include geographic region, season, and climate, as well as pollution, the latter partly due to enhanced oxidative stress. Demographic factors such as sex, age, and race are known to affect vitamin C status, as do socioeconomic factors such as deprivation, education and social class, and institutionalization. Various health aspects can affect vitamin C status; these include body weight, pregnancy and lactation, genetic variants, smoking, and disease states, including severe infections as well as various noncommunicable diseases such as cardiovascular disease and cancer. Some of these factors have changed over time; therefore, we also explore if vitamin C status has shown temporal changes. Overall, there are numerous factors that can affect vitamin C status to different extents in various regions of the world. Many of these factors are not taken into consideration during the setting of global dietary intake recommendations for vitamin C.

Multisector nutrition gains amidst evidence scarcity: scoping review of policies, data and interventions to reduce child stunting in Afghanistan

Background

Child health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries.

Methods

We reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings.

Results

We included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited.

Conclusions

This review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.

Scurvy: A New Old Cause of Skeletal Pain in Young Children

We report 3 cases of scurvy in children that occurred during a short period (2018) in a general pediatrics unit of a tertiary hospital for children in Paris. All children were around 3 years of age and were admitted for skeletal pain and altered general state, which mimicked infectious or malignant diseases. Their selective diet was not the prominent issue. The diagnosis of scurvy was delayed, after too many unnecessary examinations and medications. Bone imaging findings (X-ray and MRI) were a posteriori considered typical, but lesions were not easily identified as scurvy lesions because scurvy is not well-known by pediatricians and radiologists who should be mindful of this historical diagnosis.

Macroscopic features of scurvy in human skeletal remains: A literature synthesis and diagnostic guide

The past two decades have seen a proliferation in bioarchaeological literature on the identification of scurvy, a disease caused by chronic vitamin C deficiency, in ancient human remains. This condition is one of the few nutritional deficiencies that can result in diagnostic osseous lesions. Scurvy is associated with low dietary diversity and its identification in human skeletal remains can provide important contextual information on subsistence strategy, resource allocation, and human-environmental interactions in past populations. A large and robust methodological body of work on the paleopathology of scurvy exists. However, the diagnostic criteria for this disease employed by bioarchaeologists have not always been uniform. Here we draw from previous research on the skeletal manifestations of scurvy in adult and juvenile human skeletal remains and propose a weighted diagnostic system for its identification that takes into account the pathophysiology of the disease, soft tissue anatomy, and clinical research. Using a sample of individuals from the prehistoric Atacama Desert in Northern Chile, we also provide a practical example of how diagnostic value might be assigned to skeletal lesions of the disease that have not been previously described in the literature.

Nutritional status of pre-pregnant and pregnant women residing in Bogor district, Indonesia: a cross-sectional dietary and nutrient intake study

The diet of Indonesian women of childbearing age is relatively poor, posing increased risk for suboptimal pregnancy outcome. In a cross-sectional study including 403 women in three economic quintiles (Q), we investigated differences in dietary intake and nutrition sufficiency according to economic status and whether regular dietary intakes of pregnant women (PW, n 203) differ from that of pre-pregnant women (PPW, n 200). Dietary intake data were collected using 2×24 h dietary recall and FFQ. Energy, protein, Fe, Ca, Zn, vitamin A and vitamin C intakes were calculated utilising Food Composition Tables and compared with Indonesian recommendations for adequacy. Energy and protein intakes <70 % and Fe, Ca, Zn, vitamin A and vitamin C intakes <77 % of the local recommendation were considered insufficient. A higher intake of milk/dairy products (Q3, Q4), fruits and vegetables (Q2) and snacks (Q3) in PW was observed compared with PPW, but insufficient to meet nutrient requirements. Nutrient intake calculations showed insufficiency in 26 % of PPW for protein and up to 70 % for Fe. Deficient nutrient intakes in PW were found in 49 % of the subjects for energy and up to 85 % for Fe. Energy and protein intakes decreased with decreasing economic quintiles in PPW and PW. Ca and vitamin A intakes were lower in Q2 compared with Q4. The proportion of animal protein in Q2-PW was low (31 %). Biochemical status parameters in a subset showed that anaemia and Fe and Zn deficiencies were prevalent among PPW and PW. Habitual diets in the study area did not meet the nutrient requirements for both PPW and PW across the investigated economic groups.

The 2008 food price crisis negatively affected household food security and dietary diversity in urban Burkina Faso

Although the 2008 food price crisis presumably plunged millions of households into poverty and food insecurity, the real impact of the crisis has rarely been documented using field data. Our objective was to assess the consequences of this crisis for household food insecurity and dietary diversity in urban Burkina Faso. Two cross-sectional surveys were conducted among randomly selected households in Ouagadougou in July 2007 (n = 3017) and July 2008 (n = 3002). At each round, food insecurity assessed by the Household Food Insecurity Access Scale (HFIAS), the Dietary Diversity Score of an index-member of the household (IDDS = number of food groups consumed in the last 24 h), and food expenditure were collected. Food prices of the 17 most frequently consumed food items were recorded throughout the study area. Food prices at local markets increased considerably between 2007 and 2008, especially those of fish (113%), cereals (53%), and vegetable oil (44%), increasing the household monthly food expenditure by 18%. Thirty-three percent of households were food secure in 2007 and 22% in 2008 (P = 0.02). Individuals consumed fewer fruits and vegetables, dairy products, and meat/poultry in 2008 than in 2007 (mean IDDS = 5.7 ± 1.7 food groups in 2007 vs. 5.2 ± 1.5 in 2008; P < 0.0001). Differences in IDDS and HFIAS between the 2 y were even more marked after adjustment for confounding factors and food expenditure. Food security and dietary diversity significantly decreased between 2007 and 2008, whereas food prices increased. Households increased their food expenditure, but this was not sufficient to compensate the effects of the crisis.

Food prices and poverty negatively affect micronutrient intakes in Guatemala

Limited empirical evidence exists for how economic conditions affect micronutrient nutrition. We hypothesized that increasing poverty and rising food prices would reduce consumption of high-quality "luxury" foods, leading to an increased probability of inadequacy for several nutrients. The 2006 Guatemala National Living Conditions Survey was analyzed. First, energy and nutrient intakes and adequacy levels were calculated. Second, the income-nutrient relationships were investigated by assessing disparities in intakes, determining income-nutrient elasticities, and modeling nutrient intakes by reductions in income. Third, the food price-nutrient relationships were explored through determination of price-nutrient elasticities and modeling 2 price scenarios: an increase in food prices similar in magnitude to the food price crisis of 2007-2008 and a standardized 10% increase across all food groups. Disparities in nutrient intakes were greatest for vitamin B-12 (0.38 concentration index) and vitamin A (0.30 concentration index); these nutrients were highly and positively correlated with income (r = 0.22-0.54; P < 0.05). Although the baseline probability of inadequacy was highest for vitamin B-12 (83%), zinc showed the greatest increase in probability of inadequacy as income was reduced, followed by folate and vitamin A. With rising food prices, zinc intake was most acutely affected under both scenarios (P < 0.05) and folate intake in the poorest quintile (+7 percentage points) under the 10% scenario. Price-nutrient elasticities were highest for vitamin B-12 and the meat, poultry, and fish group (-0.503) and for folate and the legumes group (-0.343). The economic factors of food prices and income differentially influenced micronutrient intakes in Guatemala, notably zinc and folate intakes.

Detection of infectious disease outbreaks in twenty-two fragile states, 2000-2010: a systematic review

Fragile states are home to a sixth of the world's population, and their populations are particularly vulnerable to infectious disease outbreaks. Timely surveillance and control are essential to minimise the impact of these outbreaks, but little evidence is published about the effectiveness of existing surveillance systems. We did a systematic review of the circumstances (mode) of detection of outbreaks occurring in 22 fragile states in the decade 2000-2010 (i.e. all states consistently meeting fragility criteria during the timeframe of the review), as well as time lags from onset to detection of these outbreaks, and from detection to further events in their timeline. The aim of this review was to enhance the evidence base for implementing infectious disease surveillance in these complex, resource-constrained settings, and to assess the relative importance of different routes whereby outbreak detection occurs.We identified 61 reports concerning 38 outbreaks. Twenty of these were detected by existing surveillance systems, but 10 detections occurred following formal notifications by participating health facilities rather than data analysis. A further 15 outbreaks were detected by informal notifications, including rumours.There were long delays from onset to detection (median 29 days) and from detection to further events (investigation, confirmation, declaration, control). Existing surveillance systems yielded the shortest detection delays when linked to reduced barriers to health care and frequent analysis and reporting of incidence data.Epidemic surveillance and control appear to be insufficiently timely in fragile states, and need to be strengthened. Greater reliance on formal and informal notifications is warranted. Outbreak reports should be more standardised and enable monitoring of surveillance systems' effectiveness.

Negative Impact on Calorie Intake Associated with the 2006–08 Food Price Crisis in Latin America

Background

From 2006 to 2008, there were sharp increases in the prices of major food commodities globally, including maize, rice, and wheat. Few studies have contributed empirical evidence of the nutritional impacts of this food price crisis.

Objective

To assess changes in energy intake in response to food price shocks and in relation to calorie adequacy levels in seven Latin American countries.

Methods

Data were drawn from nationally representative household budget surveys. The quadratic almost ideal demand system (QUAIDS) model characterized change patterns in consumption for six food groups and one nonfood group under two scenarios: actual change in food prices by country, and standardized 10% increase in prices across all countries. Energy intakes before and after the crisis were determined once calories were assigned to food items from the ProPAN and US Department of Agriculture food composition databases.

Results

Energy intakes were reduced by 8.0% (range, 0.95% to 15.1%) from precrisis levels across all countries. Ecuador and Panama were the worst affected, followed by Haiti and Nicaragua. There was a consistent, direct relationship between wealth quintile and change in energy intake. Rural areas were affected to the same extent as or a greater extent than urban areas. High positive increases in calorie consumption were found in the richest wealth quintile, exceeding 10% of previous levels in five countries.

Conclusions

Policies and programs targeting the poorest households in both rural and urban areas may be needed to offset the energy deficits associated with food price increases. More research is needed on the effect of food prices and micronutrient nutrition.

Fermented soyabean and vitamin C-rich fruit: a possibility to circumvent the further decrease of iron status among iron-deficient pregnant women in Indonesia

Objective

Increasing the consumption of Fe-rich foods and thus improving Fe bioavailability without significantly increasing diet cost is the most sustainable intervention for improving Fe intake. We assessed the effect of supplementary food consisting of fermented soyabean (tempeh) and vitamin C-rich fruit consumed during pregnancy on maternal iron deficiency (ID).

Design

Pregnant women were randomly allocated by village into optimized diet and control groups. Supplementary food was given 6 d/week at home. The average weekly food provided comprised 600 g of tempeh, 30 g of meat, 350 g of guava, 300 g of papaya and 100 g of orange. Hb, ferritin and transferrin receptor (TfR) concentrations were measured at 12–20 and at 32–36 weeks of gestation.

Setting

Thirty-nine villages in Indonesia.

Subjects

Pregnant women (12–20 weeks of gestation, n 252).

Results

At baseline, mean Hb, ferritin and TfR concentrations and body Fe concentration were within the normal range and did not differ between groups. At near term, mean Hb, ferritin and body Fe decreased, whereas mean TfR increased significantly in both groups. The mean changes in Fe status were similar in both groups. In Fe-deficient women, consumption of an optimized diet was associated with smaller decreases in Hb (1·02 (95 % CI 0·98, 1·07) g/l; P = 0·058), ferritin (1·42 (95 % CI 1·16, 1·75) μg/l; P = 0·046) and body Fe (2·57 (95 % CI 1·71, 3·43) mg/kg; P = 0·073) concentrations, compared with a state of no intervention. Fe-deficient women at baseline benefited more from supplementary food compared with Fe-replete women.

Conclusions

Daily supplementary food containing tempeh and vitamin C-rich fruits during pregnancy might have positive effects on maternal ID.

Vitamin A intake and status in populations facing economic stress

Dietary quality and diversity reflect adequacy of vitamin A. Both can deteriorate in response to economic crises. Although the nutritional consequences of the 2008 world food price crisis remain unclear, past studies of diet, status, and socioeconomic standing under usual (deprived) and unusually disruptive times suggest dietary quality and vitamin A status decline in mothers and young children. This is presumably the result of shifting diets to include less preformed vitamin A-rich animal source foods and, to a lesser extent, vegetables and fruits. Cross-sectional assessments of diet, deficiency, and socioeconomic status in a number of countries and surveillance data collected during the Indonesian economic crisis of 1997-8 indicate that the prevalence of vitamin A deficiency, night blindness, and other related disorders (e.g., anemia) may have increased during the 2008 crisis, and that it might not have necessarily recovered once food prices waned later in 2008. Lost employment may be a factor in slow nutritional recovery, despite some easing of food prices. Vitamin A deficiency should still be preventable amid economic instabilities through breast feeding promotion, vitamin A supplementation, fortification of foods targeted to the poor, and homestead food production that can bolster income and diversify the diet.

The importance of eating rice: changing food habits among pregnant Indonesian women during the economic crisis

This article presents qualitative and quantitative research findings on food habits of pregnant Indonesian women in relation to the economic crisis that arose in 1997. Between 1996 and 1998, dietary intakes were estimated for 450 pregnant women in Central Java. Between January and June 1999, four focus group discussions, 16 in-depth interviews and four non-participant observations were held with women, two in-depth interviews were held with traditional birth attendants, and four with midwives. Women were categorized as urban or rural, rich or poor, and according to rice field ownership. The women reported that before the crisis they bought more foods and cooked more meals and snacks. During the crisis, cooking methods became simpler and cooking tasty foods was more important than cooking nutritious foods. This involved using plenty of spices and cooking oil, but reducing the use of expensive nutritious foods. The herbal drink jamu was drunk by 15% of pregnant women; its consumption was lower during than before the economic crisis. Twenty-six percent of the women avoided certain foods due to food taboos, and most of these women avoided beneficial foods; this phenomenon decreased during the crisis among the rich and the rural, poor, landless women. In spite of increased prices for rice, women did not decrease their rice consumption during the crisis because rice was believed to have the highest value for survival, to provide strength during pregnancy and delivery, and to be easier to store and cook. Finally, children and husbands had highest priority in being served food, and women were the last to eat.